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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsCareSource Georgia Abecma Prior Auth | OpenPayer
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    CurrentCareSource GeorgiaPolicy GA-MED-P-366579

    Abecma (idecabtagene vicleucel) for Relapsed or Refractory Multiple Myeloma

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    This policy governs medical prior authorization and coverage of Abecma, a BCMA-directed CAR-T therapy, for adult members with relapsed or refractory multiple myeloma. It establishes initial authorization criteria, dosing limits, approval duration, and non-reauthorization requirements.

    Policy Summary
    PayerCareSource Georgia
    PolicyAbecma (idecabtagene vicleucel) for Relapsed or Refractory Multiple Myeloma
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial revision
    Effective DateFeb 1, 2026
    Next Review DateN/A
    Key ActionSubmit medical prior authorization and document all initial eligibility criteria, including REMS enrollment, required prior therapy, ECOG status, and infection screening.
    SourceLink
    POLICY UPDATE CHANGES

    Required prior treatment history changed from four prior lines of therapy to two or more prior lines of therapy.

    Exclusions for prior hematopoietic stem cell transplant or prior gene therapy were removed.

    Dosing was updated to a single infusion of 300 to 460 × 10^6 CAR-positive T cells.

    Infection screening was revised to include CMV, HBV, HCV, and HIV.

    An ECOG performance status requirement was added.

    ≥18Minimum member age
    2+Required prior therapy lines

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ECOG 0–1
    Required performance status
    3 monthsInitial approval duration
    300–460 × 10^6Single-infusion quantity limit
    No reauthorizationContinued therapy

    Coverage Criteria

    Initial therapy for relapsed or refractory multiple myeloma

    Covered for initial authorization when all of the following are met:

    Initial therapy eligibility

    • Adult age: Member is at least 18 years of age.>= 18 years
    • REMS enrollment: Healthcare facility or provider has enrolled in the Abecma REMS program.Enrolled in Abecma REMS
    • Covered diagnosis: Member has a diagnosis of relapsed or refractory multiple myeloma (RRMM).RRMM

    • Prior therapy

      • Required prior therapy classes

        • Immunomodulatory agent: Prior treatment included an immunomodulatory agent, such as Revlimid.
        • Proteasome inhibitor: Prior treatment included a proteasome inhibitor, such as Velcade.
        • Anti-CD38 monoclonal antibody: Prior treatment included an anti-CD38 monoclonal antibody, such as Darzalex.
    • Performance status: Member has an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.ECOG 0 or 1
    • Infection screening: Member has been or will be screened for CMV, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).Screening for CMV, HBV, HCV, and HIV

    Conditions or indications not listed in this policy are excluded from medical necessity consideration. Requests for other indications should be directed to the Off-Label policy.

    Abecma is considered not medically necessary for the treatment of conditions that are not listed in this policy.

    Provider Actions

    Prior Authorization

    Initial Medical Prior Authorization Required

    Medical prior authorization is required for Abecma (idecabtagene vicleucel). Initial authorization is available when all applicable coverage criteria are met and will be approved for 3 months.

    • Member is at least 18 years of age.
    • Member has relapsed or refractory multiple myeloma (RRMM).
    • Member has persistent disease after two or more prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.
    • Member has an ECOG performance status of 0 or 1.
    • Member has been or will be screened for CMV, HBV, HCV, and HIV.
    • The allowed dose is a single infusion of 300 to 460 × 106 CAR-positive T cells.
    Step Therapy

    Required Prior Therapy

    Document that the member has persistent disease after treatment with two or more prior lines of therapy, including all three required therapy classes.

    Therapy Background

    Abecma (idecabtagene vicleucel) is a BCMA-directed, autologous CAR-T immunotherapy for multiple myeloma. The patient's T cells are harvested, genetically modified outside the body to recognize BCMA-expressing malignant plasma cells, and then reinfused to target and destroy those cells.

    Definitions

    Multiple myeloma
    DefinitionA cancer of the plasma cells in the bone marrow.
    Autologous CAR-T immunotherapy
    DefinitionChimeric antigen receptor T-cell immunotherapy in which a patient's own T cells are harvested, genetically modified outside the body, and reinfused to target malignant cells expressing BCMA.

    Initial Authorization Criteria

    Initial authorization

    Initial authorization requires all of the following criteria:

    • Adult age: Member is at least 18 years of age.>= 18 years
    • REMS enrollment: Healthcare facility or provider has enrolled in the Abecma REMS program.Enrolled in Abecma REMS
    • Diagnosis: Member has a diagnosis of relapsed or refractory multiple myeloma (RRMM).RRMM

    Continuation and Reauthorization

    No reauthorization

    Abecma will not be reauthorized for continued therapy.

    Continuation therapy: Abecma is not reauthorized for continued therapy.No reauthorization

    Required Prior Treatment

    StepRequired prior therapy classExample
    1Immunomodulatory agentRevlimid
    1Proteasome inhibitorVelcade
    1Anti-CD38 monoclonal antibodyDarzalex

    Dosing and Quantity Limits

    Quantity limit
    DrugAbecma (idecabtagene vicleucel)
    Quantity limitA single infusion of 300 to 460 × 10^6 CAR-positive T cells.
    Policy Summary
    PayerCareSource Georgia
    PolicyAbecma (idecabtagene vicleucel) for Relapsed or Refractory Multiple Myeloma
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial revision
    Effective DateFeb 1, 2026
    Next Review DateN/A
    Key ActionSubmit medical prior authorization and document all initial eligibility criteria, including REMS enrollment, required prior therapy, ECOG status, and infection screening.
    SourceLink
    On This Page
    Coverage CriteriaProvider ActionsTherapy BackgroundDefinitionsInitial Authorization CriteriaContinuation and ReauthorizationRequired Prior TreatmentDosing and Quantity Limits
    • An immunomodulatory agent, such as Revlimid.
    • A proteasome inhibitor, such as Velcade.
    • An anti-CD38 monoclonal antibody, such as Darzalex.
    Documentation Required

    Clinical Eligibility Documentation

    Submit clinical documentation supporting the diagnosis, treatment history, and eligibility for Abecma. The record should establish relapsed or refractory multiple myeloma, persistent disease after the required prior therapies, ECOG status, and required infectious-disease screening.

    • Diagnosis of relapsed or refractory multiple myeloma (RRMM).
    • History of two or more prior lines of therapy, including an immunomodulatory agent, proteasome inhibitor, and anti-CD38 monoclonal antibody.
    • Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
    • Screening completed or planned for CMV, HBV, HCV, and HIV.
    Documentation Required

    Abecma REMS Enrollment Required

    Document that the healthcare facility or provider administering Abecma is enrolled in the Abecma REMS program before authorization.

    • Abecma REMS enrollment is required for initial authorization.
    Denial Risk

    Denial Risk: Criteria Not Met or Unlisted Indication

    Coverage may be denied when the member does not meet any required eligibility or clinical criterion. Abecma is not medically necessary for conditions or indications not listed in this policy; other indications should be reviewed under the applicable Off-Label policy. Abecma will not be reauthorized for continued therapy.

    • Failure to meet the minimum age requirement of 18 years.
    • No diagnosis of relapsed or refractory multiple myeloma.
    • Failure to document persistent disease after two or more required prior lines of therapy.
    • ECOG performance status other than 0 or 1.
    • Required CMV, HBV, HCV, and HIV screening not completed or planned.
    • Healthcare facility or provider not enrolled in the Abecma REMS program.
    • Any other failure to meet the policy criteria, including dose or quantity requirements.
    • Unlisted or otherwise noncovered indication; refer other indications to the Off-Label policy.
    • No reauthorization is available for continued therapy.

  1. Prior therapy and persistent disease

    • Required therapy classes

      • Immunomodulatory agent: Prior treatment included an immunomodulatory agent, such as Revlimid.
      • Proteasome inhibitor: Prior treatment included a proteasome inhibitor, such as Velcade.
      • Anti-CD38 monoclonal antibody: Prior treatment included an anti-CD38 monoclonal antibody, such as Darzalex.
  2. Performance status: Member has an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.ECOG 0 or 1
  3. Infection screening: Member has been or will be screened for CMV, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).CMV, HBV, HCV, and HIV screening